Tag: Medicare

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CMS Provides Additional Expansion Opportunities for High Medicaid Physician-Owned Hospitals

Under the Affordable Care Act’s amendments to the Stark Law, a Physician Owned Hospital (POH) cannot expand the aggregate number of operating rooms, procedure rooms or licensed beds beyond the number for which the hospital was licensed on March 23, 2010.

The Secretary of Health and Human Services may grant an exception to this prohibition to POHs qualifying as either an “applicable hospital” or a “high Medicaid facility” (as those terms are defined in the regulations).

POHs meeting one of these two exceptions were nonetheless still limited in that they could only request an expansion once every two years and the expansion was limited to no more that 200% of the rooms or beds that existed as of March 23, 2010.

These new rules relax these expansion limitations for “high Medicaid facilities,” but not “applicable hospitals”.

Though there are other requirements, a “high Medicaid facility” POH is one that for the three (3) most recent 12-month periods for which data is available, has an annual percentage of total Medicaid inpatient admissions that is estimated to be greater than the percent of such admissions for any other hospital located in the same county in which the POH is located (as determined by the data sources approved by CMS.

The new Final Rule, removes the limitation on the number of times a high Medicaid facility can request an expansion so long as the POH only has one request under review at any given time.

CMS also removed the 200% capacity limitation that previously existed for high Medicaid facilities seeking expansion.

High Medicaid facility POHs can now expand off of their main campus, but must continue to comply with Medicare rules and regulations regarding distance limitations relative to off-campus facilities and provider-based departments.

Source: CMS Provides Additional Expansion Opportunities for High Medicaid Physician-Owned Hospitals

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Cutting Out the “Middleman”? HHS Resurrects Anti-Rebate Rule for Medicare Part D

[T]he Final Rule will modify the federal health care program’s Anti-Kickback Statute (“AKS”) safe harbors in three key ways:

First, it will remove safe harbor protection under the AKS for rebates that a pharmaceutical manufacturer provides to Medicare Part D plan sponsors (either directly or indirectly through the PBMs with which they contract). In apparent recognition of how disruptive this change will be to current business models, the Final Rule postpones the effective date for this change until January 1, 2022.

Second, it will create a new safe harbor to protect certain price reductions given by pharmaceutical manufacturers that are passed through to beneficiaries at the point-of-sale. This new safe harbor will become available on January 29, 2021.

Third, it will create a new safe harbor, also effective as of January 29, 2021, that protects certain fixed fees paid by manufacturers to PBMs for PBM services.

Source: Cutting Out the “Middleman”? HHS Resurrects Anti-Rebate Rule for Medicare Part D

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Direct Contracting Model Comes to Medicare

Under the model, healthcare providers — which CMS calls “direct contracting entities,” or DCEs — will competitively bid to manage 100% of the Medicare Part A and Part B costs for a certain number of Medicare beneficiaries within a geographic region, starting at a minimum of 30,000 enrollees. Who can be a DCE? “We anticipate interest from organizations that have significant experience taking risk in value-based care models including sophisticated Accountable Care Organizations (ACOs), health systems, health care provider groups and health plans,” CMS said in a fact sheet about the new model. “We also anticipate some applications might include innovative partnerships between health plans and health care providers.” Providers who join one of the DCEs will still be able to stay in any other value-based care programs they’re already in, including ACOs and Medicare Shared Savings Plans.

Source: Direct Contracting Model Comes to Medicare

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CMS final 2021 physician fee schedule rule

CMS issued the final rule for the 2021 Physician Fee Schedule and doctors will see a conversion factor of $32.41, a decrease of $3.68 from the 2020 PFS conversion factor of $36.09.According to CMS, the lower conversion factor is a result of the budget neutrality adjustment, as required by law, to account for changes in RVUs, including significant increases for E/M visit codes.

The decreased conversion factor is concerning to many physician advocacy groups.

Source: CMS final 2021 physician fee schedule rule

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Reimbursement Pressure in Radiation Therapy & Block Lease Arrangements

The finalized Radiation Oncology payment model and the Final CY 2021 Medicare Physician Fee Schedule (“MPFS”) have now been made public. Many in the industry will continue to face downward pressure on reimbursement during the coming year under the new MPFS payment rates set by Medicare which will drive overall cuts estimated to average 5.0% for all Medicare revenues.

Source: Reimbursement Pressure in Radiation Therapy & Block Lease Arrangements

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Eleventh Circuit Extends Scope and Time Limits for People Who Sue under the Medicare Secondary Payer Act

Medicare is the Secondary Payor when other insurance is available to pay the claim. However, when the Primary Payor delays payment, Medicare will make a “conditional payment.” If the Primary Payor fails to reimburse Medicare within 60 days, Medicare and other Medicare Advantage Organizations (MAOs) can recover double damages from the Primary Payor.

This Eleventh Circuit decision opens the door to allow “downstream actors” (the physician groups who contract with MAOs to provide care) to recover double damages from the Primary Payor.

[T]he Eleventh Circuit held that “downstream actors that have made conditional payments in an MAO’s stead or that have reimbursed an MAO for its conditional payment can bring suit for double damages against the primary payer.” Included in its reasoning, the court observed that the MSPA was intended to protect Medicare and MAOs from paying for medical costs that should have been covered by a primary payer. If a downstream actor renders a conditional payment that should have been the responsibility of a primary payer, the downstream actor suffers the same financial loss.

Source: Eleventh Circuit Extends Scope and Time Limits for People Who Sue under the Medicare Secondary Payer Act